Funding Agency
This publication was supported in part by a grant provided by the Georgia College & State University Foundation.

Abstract

Objective: Assess the availability of condoms and safer sex products as well as condom distribution procedures among college health centers nationwide. Participants: Data were collected from 358 colleges and universities. Method: Using a cross-sectional design, the authors mailed and emailed a questionnaire to a geographically representative group of 1,200 colleges and universities. Results: Majority of health centers (84.9%) offer male latex condoms to students; the most common distribution method (67%) included educational outreach. Private, as well as faith-based institutions were less likely to offer condoms to students. The M number of condoms distributed to students was 9,414/year, which equates to 1.15 condoms/student/year. Conclusions: Results may be used in primary prevention programs and may influence campus policies. Overall, results indicate that while the majority of health centers offer male latex condoms to students, the average number of condoms distributed may be insufficient to meet the sexual health needs of the collegiate population.

Introduction

Research and epidemiological data have revealed public health, medical, and economic impacts of sexually transmitted infections (STIs) and unintended pregnancy among adolescents and young adults (CDC, 2009; Chesson, Blanford, Gift, Tao, & Irwin, 2004; Institute of Medicine, 1995). According to the CDC (2009), sexually active 15 - 24 year olds are at higher risk for STIs for a variety of reasons including behavioral, biological, and cultural factors. The use of male latex condoms reduces the risk of human immunodeficiency virus (HIV), gonorrhea, chlamydia infection, and genital human papillomavirus (HPV) infection in women, and is associated with the clearance/regression of HPV and HPV-related illness (Ahmed et al., 2001; Bleeker et al., 2003; Hogewoning et al., 2003; Sanchez et al., 2003; Winer, 2006). With regard to unintended pregnancy, condom efficacy is 98% among users who exhibit “perfect use” over the course of a 1-year time period, and 85% when users exhibit “typical use” (Trussell, 2007).

Researchers at the Center for Sexual Health Promotion at Indiana University recently published findings from the National Survey of Sexual Health and Behavior (NSSHB; Reece et al., 2010a). The NSSHB is a large (n = 5,865), nationally representative cross-sectional survey of sexuality and sexual health behaviors of U.S. residents 14 - 94 years old. With regard to condom use, findings indicated that among participants who had vaginal intercourse within the last year, men 18 - 24 years old used a condom 44.9% (95% CI = 37.4% - 52.7%) of the time during their most recent 10 occurrences of vaginal intercourse and women 38.7% (95% CI = 31.0% - 47.0%) of the time (Reece et al., 2010b). Overall, findings of the NSSHB revealed that condom use over the most 10 most recent acts of vaginal intercourse was most common among participants 14 - 17 years old, followed by those 18 - 24 years old. In addition, among men and women 18 years and older who had participated in anal sex over the last year, condoms were used 20.3% of the time during the past 10 sexual encounters.

Despite the demonstrated efficacy of male latex condoms, few studies have assessed where sexually active individuals typically acquire condoms (Reece, Mark, Schick, Herbenick, & Dodge, 2010). A recent investigation by Reece and colleagues (2010) assessed condom acquisition among 1,832 men living in all 50 U.S. states ages 18 - 75 years old (M = 26.96, SD = 8.69). Results indicated that younger men (29 and younger) were more likely to receive free condoms. In addition, among those who received free condoms, several sources of acquisition were common areas housed within a college or university including a health clinic (20.5%), health fair (13.4%), dorm/student group (8.5%), and classroom (3.6%). Similar results were found among participants who purchased condoms; common acquisition included venues common to collegiate environments including pharmacy (61.0%), grocery store (28.3%), convenience store (10.9%), health clinic (3.7%), and vending machine (3.2%).

Results of the National College Health Risk Behavior Survey, conducted by the CDC, (1997), indicated that 35.1% of students reported having been pregnant or gotten someone pregnant at some point in their life. Recent findings of the Fall 2009 American College Health Association (ACHA): National College Health Assessment II survey revealed that 66.5% of college students have had vaginal, anal, or oral sex with at least one partner over the last 12 months (ACHA, 2009). Among those who had sex with at least one partner during that time, collegiate men reported a M of 2.54 (SD = 4.80) sexual partners and women a M of 1.77 (SD = 2.32) partners. In addition, among those sexually active in the last 30 days, half (51.6%) used a condom or other protective barrier for vaginal sex on most or all occasions, 30.2% for anal sex, and 6.0% for oral sex. Among those who reported using a contraceptive the last time they had vaginal sex, 61.8% used a male condom, 45.0% used a male condom in addition to another form of contraceptive, and .8% used a female condom.

Research related to condom use typically assumes that condom utilization implies correct and consistent use, as well as sufficient condom availability. Empirical studies have identified a high prevalence of condom-related errors among college age young adults (Crosby, Sanders, Yarber, & Graham, 2003; Crosby, Yarber, Sanders, & Graham, 2004; Crosby, Sanders, Yarber, Graham, & Dodge, 2002; Sanders, Graham, Yarber, & Crosby, 2003; Yarber, Graham, Sanders, & Crosby, 2004) as well as a lack of overall condom availability (Crosby et al., 2003; Crosby et al., 2002). These studies suggested that present condom distribution programs at colleges and universities seem inadequate to meet the sexual health care needs of students and that correcting misconceptions about the proper use of male latex condoms should be an educational and public health priority.

There is a plethora of research about the sexual health concerns and sexuality-related problems of college students, but little is known about the extent or comprehensiveness of sexuality-related services at college health centers. One study by Koumans et al. (2005) assessed services among higher education institutions included collected data collected in 2001 and published in 2005. The purpose of the study was to identify STI testing services, availability of Papanikolaou (Pap) tests, condom availability, and STI education procedures. Of the 910 colleges selected for participation, the investigators received completed questionnaires from 736 institutions (81% response rate). Of the institutions, 52% distributed condoms to students, including 74% of schools with a health center. When assessing demographic variables associated with condom distribution programs, student population, availability of student housing, institution type (e.g., 2-year or 4-year), and geographic location were all statistically significant. Eighty-five percent of institutions with condom distribution programs had student enrollments of 16,000 or more, 65% offered on-campus housing for students, 58% were public institutions, 64% were 4-year or more institutions, and the most prevalent geographic location with the highest prevalence of condom distribution programs was the Northeast (71%). Results of previous investigations suggested additional comprehensive studies are essential with regard to condom availability and distribution methods among college health centers.

The purpose of the present study was to assess condom and safer sex product availability, condom distribution procedures, and number of condoms distributed/year within college health centers nationwide. Specifically, the foci of the study are six fold and designed to assess the following (a) the prevalence of college health centers nationally that distribute condoms to their student population, (b) the number of condoms distributed to students/year including the M, 95% CI, Med, as well as the number of condoms given to students when adjusted for student population, (c) the relationship between student population size and the number of condoms distributed to students/year, (d) the prevalence of non-condom safer sex products distributed by health centers, (e) the prevalence of condom distribution methods located within health centers as well as those sponsored by centers, and (f) the ability of college and university demographics to predict the presence of a health center-sponsored condom distribution program.

Method

Statistical Power Estimates

A review of relevant literature as well as statistics was used to estimate sample size. McCarthy (2002) measured emergency contraceptive pill availability among college health centers. This study was similar to the present in overarching purpose, study design, and statistical outline. Based on study similarities, the sample size sufficient to detect a significant difference and to reduce Type 1 errors was estimated to be > 358. Further, based on computations by the program GPOWER (Erdfelder, Faul, & Buchner, 1996) published in Keppel and Wickens (2004), for a target power of .90 and effect size of w 2 = .06 for an independent variable with 4 levels, the present study would require 86 participants/group (344 total) to adequately meet the power estimates for sample size for all statistical comparisons between groups.

Sampling Frame

A sampling frame of 1,200 potential participants was identified to achieve the overall necessary sample size. To be consistent with McCarthy (2002), a list of 827 institutional members were obtained from the ACHA. The list provided the mailing information for individual contacts that serve as ACHA representatives. While the list provided by ACHA represents a convenience sample, it nevertheless provides the largest available list of colleges/universities with known health centers. To assess whether the list posed a potential sampling bias, a Pearson product moment correlation was computed between the prevalence of schools in individual states on the ACHA list and the prevalence of schools in states contained in the Peterson’s Guide to Four-Year Colleges (2006). Results indicated a strong positive correlation between the number of schools in the ACHA list/state and the number of schools/state in the Peterson’s Guide, r (48) =.94, p < .001.

To achieve the necessary sampling frame of 1200, an additional randomly stratified list of 373 colleges and universities was obtained from the Peterson’s Guide that was representative of each state. The Internet was used to verify if the selected institutions had a college health center. In addition, individual school contact information was obtained. When applicable, the contact information of the director of the health center, as well as his/her email address was listed in a master study directory.

Participants

Data were collected from 358 participants who currently served as directors of college health centers in the U.S. Institutionally, the participants resided in 47 U.S. states and Washington D.C. The sum of the student population of the participating institutions (n = 351) was 3.71 million students. The student population M was 10,556 (SD = 11,589). Values from the student population variable were converted to an ordinal scale of measurement to meet the assumptions of the logistic regression computations. Regional, institutional, and student population demographics are contained in Table 1. The majority of the institutions offered baccalaureate (92.7%) and master (80.7%) degrees, while 45% of institutions offered doctoral, 32.1% associate, and 20.9% offered professional degrees. In addition, 13.7% housed a medical school, 3.4% were identified as a Historically Black Institution, 2.0% were all female institutions, and .3% all male institutions.

The Directors completed the Sexual Health Services Questionnaire (SHSQ) developed by Butler, Black, Avery, Kelly, & Coster (2011). The SHSQ is a valid and reliable instrument designed to comprehensively assess the availability of sexuality-related services among college health centers. During developmental stages, college health and human sexuality professionals reviewed the SHSQ for content validity. In addition, the overall internal consistency of the instrument is .94 with individual section reliabilities from .62 - .93. The test-retest consistency of service-related items is 87.4%. The SHSQ includes 8-items regarding condom and safer sex product availability, 6-items regarding condom distribution methods, and 12-items regarding participant and institutional demographics. Condom distribution method questions included items specific to health centers and/or activities sponsored by centers including: at the campus pharmacy, at the health center after normal business hours, through an individual meeting with a health care provider at the health center, through educational campus outreach, at campus events, and through outreach efforts at bars and restaurants near campus. Service-related items are dichotomous (yes/no) with the exception of one item measuring the average number of condoms distributed to students/ year. This question read “On average how many condoms does your institution distribute to students per year? (If you do not distribute condoms please write in 0).” We were able to determine that some institutions distributed condoms, but did not provide a yearly average number of condoms given to students/year. These occurrences (n = 81) were coded as missing data.

Distribution of Surveys

After receiving approval from the campus Institutional Review Board, the initial questionnaire and consent forms were mailed to the director of the health center in waves over a 4-month period. Within 2-weeks of initial mailing, a reminder card was sent to each of the potential participants who had not returned the completed questionnaire. Finally, a second copy of the questionnaire and consent form was sent through electronic mail allowing participants to complete the survey online. Overall, the recruitment strategy was based upon recommendations made by Salant and Dillman (1994).

Statistical Procedures

Given the proposed statistical analyses of the present study, assessments of normality were conducted (Sprinthall, 2003).The following stepped approach was taken to examine parametric assumptions of interval/ratio data as previously used by Butler, Black, Gretebeck, and Blue (2004): “(a) descriptive statistics were calculated to note the relationship among the M, Med, and Mod as an indication of skewness, (b) a variety of graphics were computed such as scatterplots to detect outliers, (c) data were analyzed for normality (skewness and kurtosis) by using the Kolmogorov-Smirnov test with a Lilliefors significance correction, and (d) homogeneity of variance with the Levene Test for Homogeneity of Variance” (p. 27).

The Mann-Whitney U test and Kruskal-Wallis H tests assessed condom rank differences among the 6 demographic variables contained in Table 1. Bonferoni corrections were used to avoid risking Type I errors for these computations. Alpha values for tests of significance were computed by diving .05 by 6 (the number of rank comparisons) and set at .008. A Spearman Rho Rank Correlation Coefficient assessed the relationship between the college/university population variable and the number of condoms distributed/year variable. The Pearson Product Moment Correlation assessed associations conducted in conjunction with external validity assessments.

Pearson Simple Chi -Squared tests for external validity assessments included comparing response rates of demographic variables of the present study with those of Koumans et al. (2005) and McCarthy (2002). Only the results within the Koumans et al. (2005) study that provided data from institutions with health centers was used for comparisons. Demographic items of the SHSQ were consistent with the region (South, Northeast, Midwest, West), type of institution (public, private), and institutional setting (urban, small town, suburban, rural) variables previously used by Koumans et al. (2005) as well as the region, type of institution, residential characteristic (primarily residential, primarily commuter, equal residential/commuter) and student population size (< 5,000, 5,000 - 9,999, 10,000 - 24,999, > 25,000) variables assessed by McCarthy (2002). Bonferoni corrections were used to avoid increased risk of Type I errors. Since 7 comparisons were made, Alpha values for tests of significance were reduced from .05 to .007 for these assessments.

Results regarding the prevalence of condom and safer sex product availability as well as condom distribution procedures at college health centers are contained in Tables 2-3. Results of the univariate logistic regression model of the availability of male latex condom distribution at college health centers by demographics of responding institutions indicated that private institutions were significantly less likely to offer condoms to students when compared to public institutions, OR = .22, CI = .06 - .25, p < .001. In addition, when compared to institutions with student populations of < 5,000, colleges/universities with populations of 10,000 - 24,999 as well as those with populations of > 25,000 were more likely to distribute condoms to students, OR = 5.08, CI = 1.91 - 13.46, p = .001; OR = 5.75, CI = 1.33 - 25.00, p = .02, respectively. Finally, faith-based institutions were less likely to distribute condoms to students when compared to non-faith-based colleges/universities, OR = .08, CI = .04 - .16, p < .001. A final model was computed using multivariate logistic regression; results are contained in Table 4.

Mean, Confidence Interval, and Median Number of Condoms Distributed at College Health Centers by Demographics.

Variable

n

M

95%CI

Mdn

Entire Sample

277

9,414

6,654 - 12,174

3,000

Region

South

85

11,545

5,237 - 17,854

3,500

Northeast

79

7,012

2,646 - 11,379

3,000

Midwest

60

10,293

4,512 - 16,074

1,500

West

47

5,750

2,444 - 9,057

3,000

Type of Institution

Public

153

11,451

7,328 - 15,574

4,000

Private

118

5,688

2,543 - 8,833

1,000

Setting

Urban

107

10,803

6,279 - 15,327

3,000

Suburban

63

9,122

1,425 - 11,096

3,000

Small town

57

7,169

3,241 - 11,096

3,000

Rural

44

6,455

2,236 - 10,674

2,000

Student Population Size

<5,000

125

2,791

2,103 - 3,480

1,500

5,000-9,999

49

3,956

2,088 - 5,825

3,000

10,000-24,999

66

16,833

7,800 - 25,867

4,500

> 25,000

31

24,819

13,459 - 36,179

12,000

Residential Characteristic

Primarily Residential

107

8,424

4,451 - 12,397

2,000

Primarily Commuter

101

7,462

4286 - 10,639

3,000

Equal Residential/Commuter

63

12,193

3,977 - 20,408

3,000

Religious Affiliation

Non-Faith-Based

224

10,595

7,360 - 13,829

3,500

Faith-Based

47

1,063

422 - 1,705

0

External Validity

Multiple steps were conducted to assess the external validity of the current sample. Results of the Pearson Product Moment Correlations indicated a significant positive association between the number of colleges and universities/state in the initial sampling frame and the number of colleges and universities/state in the final sample, r (48) = .94, p < .001. In addition, a significant correlation was found when assessing the number of colleges and universities/state in the Peterson’sGuide and the number of colleges and universities/state in the final sample, r (48) = .90, p < .001.

Results of the preceding analyses indicated that the use of the ACHA convenience sample did not result in an overall sample bias based upon unrepresented geographic locations. In addition, the strong correlation between the Peterson’sGuide and the final sample of the present study provided the highest indication that the final sample in the present study is representative by state and U.S. region.

Multiple additional comparisons were made to assess if the sample size of the present study was adequate for generalizability. When assessing sample size acceptability, the overall population of colleges and universities nationally was considered (N = 4,200). Computations by Krejcie and Margan (1970) indicated that a sample of > 351 was needed to adequately represent a population of 4,000 and 354 to represent a population of 4,500. In addition, the study of ECP availability conducted by McCarthy (2002) utilized a sample of 358 college health centers nationally. The overall sample of the present study (n = 358) meets the general size requirement identified by Krejcie and Margan (1970) and is exactly that of McCarthy (2002). However, since not all statistical computations included the sample of 358, due to minor non-response rates, place some limitations on generalizability.

The present study is one of few empirical investigations to assess the availability of sexuality-related services among college health centers as well as the first to assess the M/Mdn number of condoms distributed by centers nationally. Results of the external validity assessments reveal that the sample from the present study is consistent with previous investigations assessing sexuality-related service availability at college health centers on a national basis.

Findings suggest that the majority of student health centers distribute male latex condoms to students, with the most prevalent distribution method centered upon outreach. However, while these results indicate that the majority of colleges and universities provide condoms to students, it is important to address that the M number of condoms distributed to students/year equates to only 1.15 condoms/student/year. In addition, because the number of condoms distributed/year variable was not normally distributed, the Mdn value may be an overall better indicator of the number of condoms distributed by a typical college or university. This value was computed at 3,000 condoms/institution/year which is considerably lower than the computed M. This finding suggests that increasing condom availability is a necessary priority among sexual health initiatives among college and university student health centers.

Given the similarity and overall purpose and design, it is possible to make a direct comparison between the prevalence of condom distribution programs of the present study to that of Koumans et al. (2005). Koumans et al. (2005) revealed that 74% of colleges and universities with health centers distribute condoms to students while the present study found 84.5%. This suggests that condom availability has increased by approximately 14% from 2001, indicating a positive trend in the primary prevention of STIs and unintended pregnancy during that period. However, there are several considerations that place limitations on the comparisons between findings of the present study and that of Koumans et al. (2005). The Koumans et al. (2005) investigation included a significantly larger sample size and the present study was not a direct follow-up assessment. In addition, in assessing external validity comparisons, there was a statistically significant difference in the institutional setting variable between the two studies. Finally, no direct comparisons can be made between the student population and residential characteristic variables across both studies as there were deviations in the instruments used by the investigations.

Additional results suggest that selected demographic factors significantly predict the presence of a health center-sponsored condom distribution program. Specifically, multivariate results indicate that colleges/universities with equal residential/commuter student populations were less likely to sponsor a program when compared to primarily residential institutions. Student population size also was positively correlated with the number of condoms distributed to students/year and rank comparisons indicate that colleges/universities with larger student populations also distribute more condoms. Additional research is needed to assess the role of student body characteristics upon condom availability and comprehensiveness of condom distribution programs. For example, it can be hypothesized that students who live on or near campus may be more likely to use the health center for sexual health care needs including condoms and other safer sex products. In addition, this population may be more likely to rely on on-campus health care providers which allows for greater potential for interaction. The statistically significant correlation between student population size and number of condoms distributed/year indicates that health centers should consider the overall number of students on their campus when planning and implementing primary prevention programs. Similarly, when assessing their program on an individual basis, college health professionals should consider the number of condoms given to students when adjusted for student population in concert with the Mdn number of condoms distributed by demographic or institutional characteristic.

Faith-based institutions also were less likely to offer a program when compared to non-faith-based colleges/universities, as were private intuitions when compared to public. These findings suggest that demographic factors such as type of institution and faith-affiliation act as a significant barrier to programmatic design and implementation of selected services. Results of a recent study by the authors evaluated the institutional barriers to condom distribution programs among 99 colleges and universities in rural settings nationally (Butler, Procopio, Ragan, Funke, & Black, 2011). Results indicated that the most commonly identified barrier was lack of available funds (reported among 26.3% of participant institutions), followed by expense of condoms (24.2%), lack of effective distribution methods (19.2%), and religious affiliate-based objection (18.8%). Future research is needed to assess the role of budget allocation, costs of safer sex products, distribution means such as facilities and/or supportive medical, clinical, administrative, public health, and other health professionals as well as specific religious affiliation upon sexual health service availability and utilization by student populations.

While most colleges/universities offer male latex condoms to students, results indicate less than 50% of participating institutions offer any additional safer sex product. In concert, these findings suggest that additional service development is needed to reduce the risk of unintended pregnancy and STI infection among the collegiate population. Future research is needed to assess intuitional demographic characteristics that predict the distribution of safer sex products as well as the M and Mdn number of products distributed to students/year. In addition, additional research is needed to assess the relationship between condom availability among college health centers and the prevalence of STI infection and unintended pregnancies among student populations.

Results from the present study have implications for the establishment of benchmarks for condom-related and safer sex product services at college health centers. College health professionals can use can use the data provided as a comparison for their current primary prevention efforts to reduce STIs and unintended pregnancy on their campus. Information regarding the prevalence of condom distribution programs and number of condoms distributed nationally as well as institutional/demographic characteristics can provide critical information regarding initiatives at campuses in similar settings. In addition, given the findings that suggest condom and safer sex product services be increased to meet student demand, the present study may impact sexual health policies within college and universities and encourage additional sexual health initiatives within college health centers.

The present study may have limitations. The data procured are based upon self-reported assessment of the condom-related and safer sex product services at centers. Given the overarching purpose of the investigation, self-report was selected as the most feasible procedure to collect data. In addition, the use of the health center director as the respondent may have added to the homogeneity of the sample pool and hence, increased the validity and reliability of the results. This ensured that only one respondent from each college and university was eligible to participate in the study, which may have prevented problems associated with data duplication that may have otherwise occurred.

Results of the present study regarding the prevalence of sexuality-related services are limited to college health centers and may not account for initiatives implemented at other sites within the selected colleges/universities such as those sponsored by academic departments, other units within student affairs, and other outside peer-based initiatives. Future research is needed to assess the role of initiatives in other units, institutes, or centers within the college and university setting that may play a fundamental role in condom and safer sex product distribution.

Some of the data collected from the present study contain variables with unreported responses. Such occurrences are not uncommon in health behavior research (Buhi, Goodson, & Neilands, 2008). Given the structure of the questions on the SHSQ, it is possible to accurately conclude that 84.5% (n = 304) of college health centers distribute condoms to students. However, when attempting to assess the number of condoms distributed/year, only 77.4% (n = 277) of the participants reported data. This result may place a limitation on the reported M and Mdn of condoms/year variable and limit the overall generalizability of this individual finding. It might be hypothesized that this variable in particular requires an excessive amount of time/effort or previously existing knowledge on the part of the director to obtain, which may account for the relatively high proportion of missing values.

Nevertheless, the present study is the first to report these types of findings and suggest that while the majority of colleges and universities distribute condoms to students, the M/Mdn number of condoms distributed to students/year may be inadequate. Future research is needed to assess this variable and potentially new or alternative methods of data collection may be employed to overcome these limitations.

Findings of the present investigation have implications for the establishment of benchmarks for condom-related and safer sex product services at college health centers, provide a comprehensive assessment of services on a national level, and have implications for policy development and comprehensive primary prevention programs at colleges and universities.

American College Health Association. (2009). American College Health Association - National college health assessment II: Reference group executive summary fall 2009. Linthicum, MD: American College Health Association.